Impact of the implementation of accountable care organizational structure on pediatric emergency department visits

In 2010, the United States was spending more per capita on healthcare than other similar countries but did not have better outcomes and spending was increasing at an unsustainable rate. That same year, the Patient Protection and Accountable Care Act (PPACA) was passed in an effort to reform American healthcare to improve quality while containing costs.;One way the PPACA proposed saving on healthcare was through the implementation of Accountable Care Organizations (ACOs). ACOs are a group of healthcare providers contracting to be accountable for the healthcare of a population. If they save on costs and improve quality, they retain the cost savings as profit. However, if the healthcare spending is in excess, they are at risk of losing profits. At the provider level, ACOs encourage medical homes to help coordinate care, improve wellness and manage disease through patient education and engagement. The medical homes then receive a share of the cost savings based on metrics set by the ACO surrounding cost and quality. Studies are starting to emerge evaluating the results of ACOs and associated medical homes but the literature is limited in pediatrics.;One marker of quality in pediatric asthma is the use of emergency department (ED) visits for acute asthma exacerbation. Patients with a well-understood asthma plan, education about rescue medications and with proper use of control medications should have little ED usage.;The purpose of this quasi-experimental, retrospective secondary data analysis was to evaluate the outcomes of pediatric ACO and medical home implementation as they relate to ED visits for pediatric asthma patients using a pediatric Medicaid ACO in Kansas City, MO. Insurance claims data from January 2012 through June 2015 the ACO were evaluated for changes in ED visits for asthma patients after ACO implementation, after a provider practice received medical home designation, and after implementation of a new incentive payment model. The changed in ED visits were analyzed using t-tests and regression analysis. General Systems Theory and Andersen's Behavioral Model of Health Services Use guided the formation of the study question.;The results showed an overall decrease in ED visits for patients after full ACO implementation and also with designation of medical home. Compared with the initial year (2012), there was an overall decrease in ED visits for asthma patients in the ACO in 2014 (2012: M= 0.051, SD=0.378 and 2014: M= 0.045, SD=0.321; t(356981)= 4.8, p= 0.000). There was not a statistically significant decrease in the probability of any ED visit for individual patients (2012: M=0.024, SD= 0.153 and 2014: M= 0.237, SD= 0.152; t(356891)= 0.659, p=0.25) indicating interventions likely targeted more frequent users. Medical home designation also showed a statistically significant decrease in ED visits for those practices certified versus those which were not (M= 0.028, SD=0.247 versus M= 0.043, SD=0.313); t(151111)= 9.35, p= 0.000). There was a slightly higher visit rate for those practices in the process of becoming medical home designated compared to a control group of patients cared for by non-contracted providers (p=0.03). Evaluation of the payment model found three components were associated with a decrease in ED visits: medical home recognition, expanded access and patient satisfaction measurement and improvement interventions (p=0.00).;There is a benefit to asthma patients ED visits through implementation of the ACO and medical home model supporting the intersection of General Systems Theory and Andersen's Behavioral Model of Health Services Use. This study's results are important to nursing practice because many of the targeted interventions in the ACO structure and medical home model are nursing specific. It also helps to inform policy at the national, local, and health plan level where ACOs and medical homes are promoted. Additional outcome research is needed to evaluate other improvements in disease processes and with other populations.